Similarly, there were significant group differences in fatigue at 2-month follow-up, and when the MBCT group was followed up to 6 months post-treatment, these improvements were maintained.

The MBCT group also had superior outcomes on measures of impairment, depressed mood, catastrophic thinking about fatigue, all-or-nothing behavioural responses, unhelpful beliefs about emotions, mindfulness and self-compassion.

In conclusion, MBCT is a promising and acceptable additional intervention for people still experiencing excessive fatigue after CBT for CFS, which should be investigated in a larger randomized controlled trial.

KEY PRACTITIONER MESSAGE:

Only about 30% of people with chronic fatigue syndrome (CFS) recover after cognitive behaviour therapy (CBT); thus, methods for improving treatment outcomes are needed.

This is the first pilot randomized study to demonstrate that a mindfulness-based intervention was associated with reduced fatigue and other benefits for people with CFS who were still experiencing excessive fatigue after a course of CBT.

Levels of acceptability, engagement in the intervention and rated helpfulness were high.

The Lancet PACE Trial paper was one of the two sources for the 30%-recover-with-CBT claim, although they only say this indirectly:

However, although CBT can help to reduce fatigue and disability in people with CFS, many clients do not fully recover afterwards. A paper examining CBT in routine clinical practice reported that although there were post-CBT decreases in fatigue and impairment, 70% of clients still met 'caseness' criteria for excessive fatigue (Quarmby, Rimes, Deale, Wessely, & Chalder, 2007). Furthermore, there was no additional improvement in fatigue between the end of CBT and 6-month follow-up. Similarly, in a recent multicentre trial, only 30% of CBT participants were found to have scores within normal ranges for fatigue and physical function after 52 weeks (White et al., 2011).

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The 30% figure from the Lancet paper wasn't supposed to represent recovery, although authors said things in such a way that some people might interpret it that way.

A more recent development has been mindfulness-based cognitive therapy (MBCT). This is a manualized group programme that integrates components of MBSR with interventions from CBT for depression (Segal, Williams, & Teasdale, 2002).

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The success of this intervention has stimulated others to develop similar programmes that integrate the MBSR approach with elements of CBT specific to different client groups.

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As a treatment for use in combination with CBT, MBCT has a number of potential advantages. First, it is based on the same underlying theoretical model as CBT for CFS.

How the two knit together, and the theory behind why they think MBCT might help. Can't say I'm that convinced of this as a mainstream therapy for CFS that, along with CBT, is considered sufficient to treat the condition:

Cognitive behaviour therapy models of CIS (e.g., Surawy et al., 1995; Wessely et al., 1989) propose a multifactorial approach in which particular thinking patterns, behavioural responses and emotion regulation strategies interact with physiological processes to contribute to symptoms and associated disability. For example, unhelpful thinking patterns might include catastrophic thoughts about the meaning of symptoms (e.g., This increased fatigue is a sign that I am going to become bedridden7) and the consequences of increasing activity (e.g., 'Exercise will make my CFS much worse'). Catastrophic thinking patterns are associated with greater disability in people with CFS (Petrie, Moss-Moms, & Weinman, 1995). Behavioural reactions such as excessive avoidance or restriction of activity, pushing oneself very hard despite increasing fatigue, or 'all-or-nothing7 (some-times called 'boom or bust') patterns of activity are all suggested to maintain fatigue in people with CFS (e.g., Moss-Morris, Spence, & Hou, 2011; Ray, Jefferies, & Weir, 1995, Surawy et al., 1995; Wessely et al., 1989). CBT interventions typically address unhelpful thinking and behavioural patterns by teaching thought-challenging techniques, behavioural experiments and activity scheduling, and by planning gradual increases in activity levels. Mindfulness-based approaches may be able to build this process by helping to increase awareness of unhelpful thinking and behavioural patterns as they are actually occurring. This increased present-moment awareness may provide the individual with greater opportunity to make skilful choices about how to respond rather than reacting in habitual, automatic ways. MBCT also helps individuals to develop a 'decentred' perspective on thoughts or 'metacognitive awareness' (Teasdale et al., 2002). Participants practise observing thoughts as transient mental events rather than as aspects of the self or necessarily factually correct. Here, the focus is on changing the way people relate to their thoughts rather than changing the thoughts themselves. However, it is also possible that repeatedly practising relating to thoughts from a decentred perspective will help reduce the strength of belief in negative thought content and the associated distress.

Ii addition to specific thought content being relevant to CFS, particular styles of cognitive processing may be import- ant. There is evidence that elaborative, perseverative cognitive processing, such as worrying or ruminating about one's symptoms, may lead to increased somatic symptoms such as fatigue (e.g., Verkuil, Brosschot, Gebhardt, & Thayer, 2010). Although CBT can attempt to address these processing styles, MBCT differs in that it both aims to improve awareness of early signs of worry or rumination and provides repeated practice in switching from these thinking patterns into present-moment mindful awareness.

Furthermore, the potential of MBCT to help change one's relationship to emotions may be beneficial in CFS. There is evidence to support the hypothesis by Surawy and colleagues (1995) that people with CFS tend to have more negative beliefs about the acceptability of experiencing and expressing negative emotions compared with healthy people (Rimes & Chalder, 2010) and may overcontrol negative emotions (Caseras et al., 2008). Research suggests that attempting to avoid or suppress negative emotions may be counterproductive (e.g., Dalgleish, Ylend, Schweizer, & Dunn, 2009). Although unhelpful beliefs about emotions may be addressed in CBT (Rimes & Chalder, 2010), MBCT invites experiential practice in relating to emotions in new ways, hi particular; MBCT encourages individuals to allow unwanted emotions to be present and explore them with compassion rather than attempting to avoid or suppress them. It has been suggested that mindfulness approaches may be particularly effective for clinical syndromes where intolerance of negative affect plays a role (e.g., Bishop et al., 2004). Similarly, developing new ways of relating to physical sensations, especially greater acceptance, may also be important for people with CFS. Evidence from cross-sectional research suggests that greater acceptance of fatigue symptoms is associated with lower levels of fatigue in people with CFS (Van Damme, Crombez, Van Houdenhove, Mariman, & Michielsen, 2006). Acceptance of physical sensations is not typically a key focus within CBT for CFS.

Finally, CBT models of CFS suggest that the ways of relating to the self may be important. People with CFS tend to score higher on measures of unhelpful perfectionism than healthy individuals (Deary & Chalder, 2008), and there is evidence from prospective studies that negative perfectionism is associated with the development of fatigue problems (Dittner, Rimes, & Thorpe, 2011; Moss- Morris et al., 2011). Although perfectionist beliefs are typically addressed in CBT for CFS, the central focus on self-compassion in MBCT could provide further benefits. MBCT may help individuals to cultivate new, kinder ways of relating to themselves that are helpful antidotes to perfectionist and self-critical attitudes. There is evidence that increases in self-compassion mediate outcome for MBCT for depressive relapse (Kuyken et al., 2010).

In conclusion, the cognitive behavioural model of CFS indicates a number of ways in which an adapted version of MBCT could be a helpful additional intervention for people with CFS. This is the first study to the authors' knowledge that examines an additional treatment provided for people with CFS who are still experiencing excessive fatigue after CBT. Research guidelines such as those by Craig and colleagues (2008) for the Medical Research Council suggest that preliminary studies be conducted prior to any major trial that seeks to evaluate a complex intervention. The aim of the present study was to explore the acceptability of this intervention and the feasibility of undertaking a larger-scale randomized controlled trial. Preliminary investigation of the impact of this new intervention was also undertaken. Participants were randomized to either immediate MBCT or waiting list (WL). It was hypothesized that when controlling for pre-treatment scores, the people in the MBCT group would report lower fatigue (the primary clinical outcome) and impairment at the end of treatment than the WL group. Secondary hypotheses were that the MBCT group should show greater self-compassion and mindfulness and lower levels of catastrophic thinking about symptoms, 'all-or- nothing' behaviour and unhelpful beliefs about emotions than the WL group at the end of treatment. The effect of the intervention on depression, anxiety and physical functioning was examined. The groups were also compared at 2-month follow-up; at this point, the WL group began their own MBCT programme, and thus the MBCT group alone were followed up to 6 months post-treatment.

You know when I did a 13 week course on CBT and Mindfulness a couple of years ago, those in charge were clear - as were the patients at the end - "This will not remove your illness [I was the only one there with ME - there were people with cancer (pre- and post treatment), physical injuries causing chronic pain, MS, and other things including chronic depression] but what we hope it will do it put your illness into perspective and provide you with a better sense of control."

And it did - for me at least. All this crap about CBT and/or Mindfulness 'curing' people is, well, crap. It can help restore what is lost through despair and struggling to come to terms with a chronic condition - especially one for which there is no specific treatment or understanding. It can teach coping skills and strategies. It ain't no frickin' cure!

People can and do feel better after having a natter and learning that they aren't alone; picking up some strategies and management plans. People will even say that 'it helped'. It is I have no doubt - possible to take onboard the principles of Mindfulness and CBT to such an extent that you can effectively side-line your health more readily: and pursue other things more successfully than before.

But it ain't no frickin' cure - unless perhaps you are diagnosed solely with e.g. depression or somesuch: and then I can see it being perceived as such by patient and doctor.

Three people were excluded prior to invitation because their therapist judged that they had interpersonal difficulties that would make a group intervention unsuitable for them or for other participants.

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Some ME support group leaders can't do this. I don't know what exactly "interpersonal difficulties" are specifically e.g. how would one test for them.

I agree, @Firestorm. I've practiced mindfulness meditation for almost 35 years, and I got sick 25 years ago. It has helped enormously with managing my relationship with this illness. It has absolutely helped.

But it has no effect on any physical symptoms - PEM, insomnia, memory loss etc. If they asked the question right, they could get me to say it helps with fatigue, but that's because I'm making up for some sleep deficit by laying down and being absolutely still for an hour or 2 a day.

The mindfulness course consisted of an introductory session, followed by eight weekly sessions, each lasting 2.25h. The 8-week structure and mindfulness practices followed the Segal et al. (2002) MBCT manual. Classes included mindfulness meditation practices and these are also undertaken at home, usually with the support of CDs. hr each class, there was the opportunity for participants to talk about their experiences with the mindfulness practices, the obstacles that had arisen, and how to deal with them skilfully. Each class was organized around a theme that was explored through both group inquiry and mindfulness practice. The programme was adapted so that psycho-educative and cognitive components were consistent with a cognitive behavioural model of CFS (Surawy et al., 1995) rather than depression. The intervention was aimed at helping participants to become more aware of and to relate differently to their thoughts, feelings, bodily sensation and self, including the development of greater metacognitive awareness and a more accepting, non-judgemental and compassionate attitude. It was intended to help individuals to disengage from unhelpful cognitive and behavioural reactions that may be inadvertently maintaining symptoms, impairment and/or distress and to develop new ways of responding. For all practices, especially the movement practices, participants were reminded that they could modify, take breaks from or abstain from practices as they felt appropriate, including imagining the movements rather than physically moving if they chose to. Participants were offered a 2-month fol¬low-up mindfulness class that included mindfulness practices and enquiry, a review of the participants' current mindfulness practice and future practice intentions. The classes were led by two clinical psychologists who met the requirements of the Good Practice Guidance for Teaching Mind fulness-based Courses (UK Network of Mindfulness-based Teacher Trainers, 2010). The psychologists were supervised separately by experienced mindfulness instructors. The MBCT was conducted in two separate groups, the first with 11 participants and the next with 7 participants.

An additional multiple choice question was included: 'How useful has the mindfulness course been to you?' with response options of 'no use at all', 'quite useful', 'useful', 'moderately useful' and 'very useful'. (Analysis of qualitative feedback about what had been learnt will be reported separately)
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All of the MBCT completers rated the intervention as useful, with 88% rating it as 'very useful'.

Some ME support group leaders can't do this. I don't know what exactly "interpersonal difficulties" are specifically e.g. how would one test for them.

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Doesn't play well with others?

Seriously, some folk do have anger issues and don't like to be confronted. Then there's those who really struggle in groups or crowds. I can think of a few people who would certainly rather not be in 'group therapy' though they'd also want to punch anyone for claiming they had 'interpersonal difficulties'

Seriously, some folk do have anger issues and don't like to be confronted. Then there's those who really struggle in groups or crowds. I can think of a few people who would certainly rather not be in 'group therapy' though they'd also want to punch anyone for claiming they had 'interpersonal difficulties'

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Yes, I'm not disagreeing with what they did or what you said. Just wondering about the specifics.
Also thought it was worth noting as an interesting issue in itself which doesn't get mentioned much when talking about running groups (although complaining about individuals does, just no title is put on their behaviour).

Only one participant who began the MBCT dropped out, mainly because she did not like the group nature of the intervention.

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The effect sizes were relatively modest, and the mean post-MBCT fatigue scores were not down to population norms, even at 6-month follow-up.

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The overall feedback about the MBCT, e.g., the rating as 'very helpful' by 80% of participants, perhaps indicates a larger impact than might be indicated by the fatigue effect size.

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Or perhaps simply a case that single-item questions on satisfaction and the like often get high ratings.

Satisfaction ratings may be influenced by demand effects, but this finding is consistent with anecdotal reports from mindfulness instructors that MBCT participants report a wide range of benefits that are difficult to capture on a restricted set of standardized measures.

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Mindfulness instructors might not be the most objective sources .
Also, my guess is that a lot of the benefits are more psychological, rather than "physical", but the authors aren't making such a distinction.

Another drawback of this design is the lack of an active treatment control group, and improvement in the treat¬ment group may have been due to nonspecific factors such as patient expectations, therapist attention and social support, and so on.

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The study also relied on self-report, which may have been open to demand effects or other biases.

Let's spend some money on a trial comparing CBT with Mindfulness with Paul McKenna's hyptonism on stress with eating a banana!

I know it's all 'science' of a sort and these folk are in pursuit of the 'best fix' but really. For the results they are getting - despite fixing them - is it really worth it? Talk about trying to justify an existence.

When someone embraces me, or even talks to me, and I feel better: I don't know why. I just do. I don't need a bloody science paper trying to determine the best way of embracing, or talking.

Enough. I need to watch a film. I don't know why it makes me feel better. It just does. I might conduct a few experiments. I might ask for a large grant